2.0 Analysis 2.1 Departure Preparations The operator of the boat has worked as a fisherman since 1974 and occasionally serves as master of small passenger-carrying boats for TAN Inc. At the time of departure, the operator had had a rest period and the 1500 cruise was to be his first of the day. Before departure, the operator checked the fuel and the oil and started both engines, which turned over promptly. He then reported his departure and the number of persons on board to VTC Les Escoumins. The passengers received no pre-departure safety briefings, but they were told to distribute themselves evenly in the boat. The place where the lifejackets were stowed was not clearly indicated. 2.2 Flooding of the Boat Because of the state of the sea on the St. Lawrence River, the boat stayed close to the shore during the cruise. When the boat travels at reduced speed or is still, water can enter through the opening in the transom, but when the boat speeds up, the water flows outward because of the Venturi effect. Water began to flood the boat by the stern when both motors failed. The passengers were up to their knees in water when the pressure of the water accumulated in the bottom lifted the lid of the locker where the lifejackets were stowed. The passengers donned the lifejackets, but, before they could fasten them properly, the boat capsized and sank by the stern. 2.3 Passenger Survival When the TAN 1 capsized, nine passengers and the operator were rescued by the TAN 3, which was a short distance from the scene of the sinking. The three other passengers clung to the bow of the TAN 1 until they were rescued by two other Zodiac-type inflatables operating in the area and by the pilot boat. Although they were worn, the wetsuits did enable the passengers to remain afloat and did slow the loss of body heat, thereby preventing hypothermia. The operator of the boat was wearing a buoyancy vest and rubber boots. He had to be admitted to hospital where he was treated for a drop in his body temperature. Three passengers who were wearing wetsuits had to be treated because they were chilled. 2.4 Design of the Fuel Supply System Laboratory tests were performed to analyze the likely reasons for the two outboard motors stalling. The boat's owner stated that the starboard motor had stalled a number of times since the beginning of the season. The boat had returned to the wharf several times from a cruise with only one motor working. These intermittent failures were at least partly due to the accumulation of water in the needle valves of the carburettors. When water accumulates in a carburettor, the fuel is held momentarily toward the cylinders, and the engine stalls. Furthermore, the fuel supply system was fitted with four coalescing paper filters that were not designed to retain water from the fuel. However, there are filters on the market, specifically designed for marine use, that do retain water from fuel before it reaches the carburettor. A water accumulator of the type used for recreational vehicles had been installed in the tank of the TAN 1; this suggests that the owner was worried about the presence of water in the fuel. This type of accumulator, however, is designed to recover water in a fuel tank caused by condensation where the quantity of fuel is small. The fuel also could have been contaminated with water through the supply system as well as through the vent pipe, which had no mechanism to prevent water from leaking in. The suction in the tank for supplying the starboard motor was 30 mm behind the one serving the port motor; during acceleration, the water, with a specific density greater than that of fuel (in the present case, gasoline), moved toward the back of the tank thereby causing the intermittent failures due to suction of water rather than fuel. 2.5 Arrangements to Counteract Flooding The boat was fitted with two bilge pumps; one manual and the other electric. The manual pump, fitted on the port side of the boat near the steering position, was not operational because the inlet and outlet couplings were not connected and the piece of wood used as a lever to operate the pump was missing. The electric pump, with a capacity of approximately 9,000 litres an hour, was connected to a three-way switch (Auto, Off, Manual) as indicated on the control console; it was connected to a fuse and an indicator light. The DC power supply was checked, and the fuse was in good condition. It was further observed that when the switch was set to Manual, the bilge pump could operate continuously only if the switch was kept in that position. When the boat reached the TSB Engineering Laboratory, the bilge pump switch was set to Auto. In this position, the pump operates only if it is connected to a float indicating the water level, and it comes on when water is detected accumulating in the bilges. In the course of the laboratory tests, it was noted that the indicator light, located above the bilge pump switch, was not connected to any power source. No float or wiring which could have served such a purpose was found in the hold. The bilge pump was removed and tested, and it proved to be in good working order. Nothing indicates that the operator was aware that the bilge pump was not operational. 3.0 Conclusions 3.1 Findings The fuel was contaminated because the fuel tank and fuel filters of the fuel supply system were inadequate. The TAN 1 capsized because there was no effective means of evacuating water which accumulated on board. Neither the manual nor the electric bilge pump was operational before departure. The capsizing of the TAN 1 happened unexpectedly, and all the occupants were thrown into the water. The location of the lifejackets was not indicated and the passengers had received no safety instructions regarding the lifejackets before departure. The operator was wearing a Mustang vest whereas the passengers were all wearing wetsuits, some of which had holes in them. The operator and three passengers were chilled when they were rescued. Considering the design of the boat and the condition of the motors, the TAN 1 was not seaworthy. 3.2 Causes The outboard motors of the TAN 1 stalled and could not be restarted because the fuel was contaminated with water. Shortly thereafter, the drifting boat was flooded by the stern and eventually capsized. 4.0 Safety Action 4.1 Action Taken 4.1.1 Seaworthiness In March 1994, the TSB Engineering Laboratory examined the TAN 1 and produced a survey report. In May 1994, the Canadian Coast Guard (CCG) was informed of safety deficiencies that jeopardized the seaworthiness of the TAN 1, in particular: water contamination of the fuel due to the size and location of the vent pipe and to the lack of a marine filter to retain water; the fuel gauge on the control console was not connected to a level detector in the tank; the filling hole of the fuel tank was cracked and the cap had two vent holes through which water could enter the tank; several other shortcomings of the tank constituted a fire hazard; the motor control levers were improperly adjusted; the electric and the manual bilge pumps were not operational; and the boat did not meet the Construction Standards for Small Vessels (TP 1332) from Transport Canada. Although the TAN 1 was not legally bound to meet the regulatory requirements, the CCG, upon receipt of the TSB letter, provided technical advice to the owner of the TAN 1 with a view to remedy the deficiencies noted. 4.1.2 Modifications In 1994, the owner made several improvements to the TAN 1: the stern was enclosed and six watertight tanks were built along the sides of the boat; a stern watertight tank provides more flotation under the motors; two 250-litre fuel tanks were installed in a watertight compartment fitted with a fume detector and a bilge air vent; the filters of the fuel supply system were replaced; two new outboard motors (200 HP each) were installed; a new electric and manual bilge pumping device was installed; the control console was modified to incorporate the very high frequency (VHF) radio antenna and a more efficient radar reflector. A new radar and an independently battery-powered radiotelephone were added to make the boat safer. 4.1.3 Safety of Small Sight-seeing Boats In its report on the investigation into the grounding of the TAN 1 on 11 August 1993, the TSB issued three marine safety recommendations aimed at making small sight-seeing boats safer (TSB Report No. M93L0003). The Board recommended that: The Department of Transport develop training standards and certification requirements for the operators of small sight-seeing boats that carry fare-paying passengers; The Department of Transport amend the regulations to require sight-seeing boats that carry fare-paying passengers to be fitted with adequate radio equipment and to report to the VTC, before departure, the number of persons on board; and The Department of Transport and the Department of Fisheries and Oceans, in cooperation with police forces and SAR personnel, explore means of improving the monitoring and inspection of small passenger-carrying commercial vessels. 4.2 Action Required 4.2.1 Construction Standards and CCG Inspections The TAN 1 and other similar five-ton category boats are not required to undergo CCG safety inspections as prescribed in the Hull Inspection Regulations. The TSB Engineering Laboratory tests revealed several deficiencies, inter alia, regarding the construction of the hull, the fuel tank and the maintenance of the motors. Furthermore, the substandard design and construction of the fuel tank and stern transom allowed the ingress of seawater into the fuel tank which led to the contamination of the fuel supply system of both outboard motors. In addition, the defective bilge pumps were unable to discharge the water and there was no other means to bail the water. Under these conditions, the TAN 1 was not seaworthy, and capsized. In 1993, as a parallel measure to the by-then defunct Small Passenger Vessel Compliance Program, the Quebec office of the Ship Safety Branch of the CCG randomly inspected 18 small sight-seeing boats in the area of Tadoussac, Quebec. None of these boats complied with the regulations as safety equipment was either defective or missing altogether, and notices were issued to that effect. The most common deficiencies noted were lifejackets; navigation lights; radio operator's certificates; radar reflectors; distress signals; lifebuoys; fire extinguishers; anchors, and bilge pumps. Every year, more than 40 sight-seeing boats are operated in the Tadoussac area without having been inspected by the CCG, but the passengers who board these small boats assume that they are seaworthy and safe. In the Laurentian region, there are more than 100 boats of all shapes and sizes offering sight-seeing cruises. In the absence of mandatory requirements, CCG surveyors do not have the necessary regulatory instruments to improve the safety of these boats. They rely on the operators to maintain their boats in a seaworthy condition. However, many operators do not have the level of knowledge necessary to properly assess the safety shortcomings. As a result, passengers are unwittingly exposed to inherently unsafe operations in that the vessels they board may not be seaworthy or the life-saving or emergency equipment may not be adequate. The Board therefore recommends that: The Department of Transport require all small boats that carry fare-paying passengers to undergo safety inspections to ensure their seaworthiness and operational safety. M96-04 Assessment/Reassessment Rating: Fully Satisfactory 4.2.2 Safety Instructions Every year, often in adverse weather conditions, a large number of small sight-seeing boats carry passengers along the St. Lawrence estuary. The vast majority of these passengers are not familiar with the life-saving equipment and survival techniques used in marine emergency situations. Normally, the passengers are not informed of safety measures to be taken under normal conditions and in emergency situations. Indeed, in this occurrence, the passengers had no knowledge of the location or use of the lifejackets carried on board since they had received no pre-departure instructions regarding the life-saving equipment. Given the operating conditions and the lack of formal safety and operating standards, the Board believes that, in order to reduce the severity of accidents and to better prepare for emergency situations, passengers must be well informed of any safety precautions and measures that apply to them. Therefore, the Board recommends that: The Department of Transport require the operators of small sight-seeing boats to provide pre-departure safety instructions to the passengers for normal operating conditions and for emergency situations.